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Medication Errors

Cohen, Michael R., ScD, MS, RPh

doi: 10.1097/01.NURSE.0000552708.88620.c0

Near-miss mix-up of nebulizer solutions...patients need more education to use pen needles correctly...tool available to mitigate the risk of tubing misconnections


The reports described in Medication Errors were received through the ISMP Medication Errors Reporting Program. Report errors, close calls, or hazardous conditions to the Institute for Safe Medication Practices (ISMP) at, 1-800-FAIL Safe, or Michael R. Cohen is a member of the Nursing2019 editorial board.

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Near-miss mix-up of nebulizer solution

A close call occurred at a children's hospital in which racepinephrine (Asthmanefrin) inhalation solution was mistaken for ipratropium bromide inhalation solution due to look-alike packaging. The unit-dose vials of both products, manufactured by Nephron Pharmaceuticals Corporation, come in similar bar-coded overwraps with a white background and green panels that display the nonproprietary names in a small, white font, as shown below. Fortunately, the dispensing mix-up was noticed before any patients received the wrong drug.



Although both products are bronchodilators, their pharmacology differs; ipratropium is an anticholinergic, whereas racepinephrine is a nonselective alpha- and beta-adrenergic receptor agonist. The company recently revised the racepinephrine label to help differentiate the products, as shown above. Scanning the bar code on the overwrap can also help verify that the correct product is being dispensed and administered.



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FDA calls for better patient education

A recent FDA Safety Communication cautions patients and clinicians about the misuse of pen needles by patients. Standard pen needles for pen injectors have an outer cover and a removable inner needle cover, which are both manually removed before an injection. Safety pen needles have an outer cover that is removed and an inner needle shield that is not removed before an injection. Because most hospitals use safety pen needles to protect staff from needle sticks, nurses may teach patients to self-inject a medication using a safety needle. Patients who later purchase standard pen needles may not know to remove both the outer and inner covers. If patients leave the inner cover on, the needle will not enter the skin at the time of injection and none of the medication will be administered. Although some medication may leak out from the inner cover, patients may not notice a problem.

The FDA communication lists recommendations for both patients using pen needles and providers who care for these patients. In addition, the FDA asked needle manufacturers to review educational materials to assess the need for updates to clearly explain how to use pen needles safely. The FDA also requested that manufacturers of standard pen needles consider adding a warning in the labeling regarding the need to remove both the outer cover and the inner needle cover before use.

The FDA Safety Communication can be found at

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Assess the risk of tubing misconnections

Catheter and tubing misconnections are a serious problem in healthcare. In 2012, ISMP collaborated with Baxter Healthcare's Clinical Center of Excellence to develop a self-assessment tool for healthcare facilities. Recently updated, this tool guides users through a modified risk assessment that evaluates current delivery systems and mating devices, rates ease of connection and potential for patient harm, and assigns a risk priority score. This is an excellent resource to help hospitals mitigate the risk of tubing misconnections. Access it at

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